Comparison of open and endourologic approaches to the obstructed ureteropelvic junction

Robotic pyeloplasty learning curve for a pediatric surgeon without previous laparoscopic pyeloplasty experience

Robotic pyeloplasty has become a technique of choice for pyelo-ureteral junction syndrome treatment in children. Less invasive than open surgery, robotic pyeloplasty also has a lower learning curve than laparoscopic pyeloplasty. This is how a new generation of surgeons without previous laparoscopic pyeloplasty experience has begun training in robotics. To assess the robotic assisted pyeloplasty learning curve for a pediatric surgeon only trained in open pyeloplasty, and to investigate if that mode of practice is safe and effective. Data were collected from all children operated on for pyelo-ureteral junction syndrome by the same surgeon in our center between 2015 and 2021. Cases were divided into 4 groups of 14 consecutive procedures to analyze the learning curve. Fifty-six patients were operated on, with a median (IQR) age, weight, and hospital stay of 9 years and 1 month old (3.5), 29 kg (17.3), and 3 days (2), respectively. The mean ± SD operative times were 146.5 ± 39.3, 123.2 ± 48.1, 103.1 ± 29.5, and 141.7 ± 25.0 min, with a unique significant difference between groups 1 and 3 (p = 0.007**). Only two intraoperative and nine postoperative complications were observed. The surgery was successful in 98% cases. Our study shows that a significant improvement in surgical time could be achieved in the first 30 cases, safely and efficiently even without previous laparoscopic pyeloplasty experience.Level of evidence: III.

Mini-laparotomy in-situ pyeloplasty for repair of the ureteropelvic junction obstruction: Outcome of 150 cases

OBJECTIVE

To evaluate the functional and cosmetic outcomes of using the mini-laparotomy technique In Situ pyeloplasty to repair UPJ obstruction in young infants less than 6 months.

MATERIALS AND METHODS

Between January 2014 and March 2020, 150 young infants (less than 6 months) diagnosed with unilateral ureteropelvic junction obstruction (UPJO) and treated by mini-laparotomy In Situ pyeloplasty were included in this analysis. Once the UPJ has been identified, it was grasped by an Allis forceps for gentle traction. Two facing transverse incisions were made in the dilated pelvis facing the upper ureter. The transverse ureteric incision was then opened longitudinally. An anastomosis was done between the most dependent part of the lower lip of the pelvis and the apex of ureteric spatulation using 6/0 polyglactin (Vicryl®) sutures in the direction of "out-in-in-out." Follow-up was scheduled for 1 month and then every 3 months for a year with abdominal ultrasonography. DTPA was done for all patients 1 year after repair.

RESULTS

The mean age was 3 ± 0.5 months, and the mean follow-up was 1.5 ± 0.3 years. Our technique was done in all included patients with a functional success of 96% (all patients restored normal function, and no obstruction was reported). Parents were satisfied with the cosmetic appearance of the wound in 91% of cases. Major complications occurred in 4% of cases.

CONCLUSION

Successful repair of ureteropelvic junction obstruction in young infants can be achieved by using mini-laparotomy In Situ pyeloplasty technique with satisfactory functional and cosmetic outcomes.

Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Children: Value of Robotic Assistance

AIM

Retroperitoneal pyeloplasty (RP) for pediatric ureteropelvic junction obstruction (UPJO) performed using retroperitoneoscopy (retro-RP) or robotic assistance (robo-RP) were compared.

METHODS

All subjects were Japanese, matched for age, weight, and RP diameters. All RP were performed in the lateral decubitus position at a single institute by the same team using identical protocols. Five independent surgeons were asked to score intraoperative video recordings for perceived difficulty of suturing (DOS; 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; 1 = easy) and rank RP as +1 if robo-RP appeared to be superior, 0 if they appeared to be the same, and -1 if robo-RP appeared to be inferior.

RESULTS

Robo-RP performed 2018-2022 (n = 22) were matched with retro-RP performed 2011-2019 (n = 34). Mean overall operative times were similar (robo-RP: 305.2 ± 57.8 min versus retro-RP: 340.0 ± 117.9 min; p = 0.19), but securing the larger retroperitoneal space required for robo-RP took significantly longer; 50.8 ± 13.9 min versus 24.3 ± 9.6 min; p < 0.0001. Total anastomotic time (TAT) and TAT per suture were both significantly shorter for robo-RP (p < 0.0001). The coefficient of variation for time taken to place one suture was smaller for robo-RP than for retro-RP. DOS was lower for robo-RP with less variance (p < 0.01). Robo-RP had shorter drainage tube insertion, ambulated quicker postoperatively, and shorter hospitalization. Retro-RP had anastomotic complications; leaks (n = 2) and strictures (n = 2, requiring conventional open re-pyeloplasty). Robo-RP had no anastomotic complications and was ranked +1 unanimously.

CONCLUSIONS

The RP anastomosis was quicker with less complications and more precise with robotic assistance in matched patients under similar circumstances. Should RP be indicated, robo-RP is recommended.

LEVEL OF EVIDENCE

III.

Pyeloplasty with the Kangduo Surgical Robot vs the da Vinci Si Robotic System: Preliminary Results

Objective: To share our experience in robot-assisted pyeloplasty (RAP) with the Kangduo (KD) surgical robot vs the da Vinci Si (DV) robotic system (KD-RAP vs DV-RAP, respectively). Methods: From August 2019 to February 2021, 16 patients with ureteropelvic junction obstruction (UPJO) underwent KD-RAP and other 16 patients with UPJO accepted DV-RAP. All procedures were performed by the same surgeon. The perioperative results and follow-up data were prospectively collected and compared. Results: There was no conversion to open or laparoscopic surgery. The mean operation time was significantly longer in the KD-RAP group than the DV-RAP group (141 ± 28 minutes vs 118 ± 31 minutes, respectively, p = 0.04). The time per stitch was significantly longer in the KD-RAP group than the DV-RAP group (1.7 ± 0.5 minutes vs 1.4 ± 0.3 minutes, respectively, p = 0.05). No significant difference was noted in the estimated blood loss and the postoperative length of hospitalization. At a median follow-up of 19 (range 17-21) and 19.5 (range 14-33) months for the KD-RAP and DV-RAP groups, respectively, no difference was noted in the success rates between the KD-RAP and DV-RAP groups (93.75% and 100%, respectively; p = 0.31). Complications were comparable between the two groups (p = 0.54). One (6.3%) patient developed urinary infection, which responded well to oral antibiotics in KD-RAP group and 2 (12.5%) patients suffered from irritation symptoms of bladder, which improved after removal of Double-J stent in the DV-RAP group. Conclusions: The RAP with the use of the KD system was feasible, safe, and effective. The DV-RAP group showed advantage in the operation time and the time per stitch.

A nomogram to predict stricture-free survival in patients with ureteral stricture after balloon dilation

Background

Balloon dilation is a commonly used minimally invasive endourological treatment of ureteral stricture, but the postoperative recurrence rate is relatively high. And factors contributing to recurrence after treatment are poorly understood. Herein, we sought to develop a novel clinical nomogram to predict ureteral stricture-free survival in patients suffering from ureter stricture and performed balloon dilation.

Methods

The nomogram was established based on a retrospective analysis of 321 patients who received endoscopic balloon dilation alone for ureter strictures from January 2016 to January 2020 in Sun Yat-sen Memorial Hospital using the Cox regression model. Perioperative clinical data and disease outcomes were analyzed. The primary endpoint was the onset of ureteral re-stricture after ureter balloon dilation. Discrimination of the nomogram was assessed by the concordance index (C-index) and the calibration curve. The results were internally validated using bootstrap resampling.

Results

Overall, 321 patients with a median follow-up of 590 days were enrolled in the study, among which 97 patients (30.2%) developed recurrence of ureteral stricture during follow-up. Five variables remained significant predictors of ureteral re-stricture after multivariable analyses: stricture nature (P < 0.001), urinary nitrite (P = 0.041), CKD (P = 0.005), stent retention time (P < 0.001), and balloon size (P = 0.029). The calibration craves for the probability of 1-, 3-, and 5-years stricture-free survival (SFS) presented satisfied with the consistency of nomogram prediction and actual observation. The C-index of the model was 0.74 (95% CI 0.70–0.79).

Conclusions

Our study developed the first nomogram to effectively predict stricture-free survival in patients suffering from ureter stricture after balloon dilation. It is helpful to identify the optimal patients with ureter stricture for balloon dilation and improve treatment outcomes. However, further external validation of the nomogram is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00896-3.

[A retrospective comparison of robotic assisted and conventional laparoscopic pyeloplasty in two centres]

Ziel

Wir verglichen in unserer retrospektiven Multicenterstudie die Ergebnisse der konventionell laparoskopischen Nierenbeckenplastik (L-NBP) mit denen der roboterassistierten Nierenbeckenplastik (R-NBP) nach Einführung des da Vinci X-Systems.

Methoden

Insgesamt wurden im definierten Zeitraum von Mai 2015 bis September 2019 76 Nierenbeckenplastiken an zwei unterschiedlichen Universitätskliniken durchgeführt. Für die Datenanalyse wurden 63 Patienten berücksichtigt, welche entweder eine L‑NBP (n = 27) oder eine R‑NBP (n = 36) nach Anderson und Hynse erhielten.

Ergebnisse

Das mediane Follow-up lag bei 22,5 (L-NBP) bzw. 12,7 (R-NBP) Monaten. Die statistische Analyse der Patientengruppen ergab bzgl. Alter, BMI, Geschlecht und betroffener Seite keinen statistischen Unterschied. Die Operationszeit war in der Gruppe der R‑NBP nicht statistisch signifikant kürzer (180 ± 72 vs. 159 ± 54 min, p = 0,194). Bezüglich postoperativer Major- bzw. Minor-Komplikationen nach Clavien-Dindo, Krankenhausaufenthaltsdauern (7,48 ± 2,86 vs. 6,33 ± 2,04 Tage) und Erfolgsrate ergab sich ebenso kein statistisch signifikanter Unterschied.

Schlussfolgerung

Unsere Daten zeigen keinen signifikanten Unterschied der beiden Gruppen bezogen auf die peri- und postoperativen Ergebnisse. Es konnte gezeigt werden, dass für den Patienten auch unmittelbar nach Implementierung eines robotischen Systems kein Nachteil entsteht.

Single-Port Robot-Assisted Dismembered Pyeloplasty With Mini-Pfannenstiel or Peri-Umbilical Access: Initial Experience in a Single Center

OBJECTIVE

To assess the feasibility and describe the surgical technique for single-port robotic-assisted laparoscopic pyeloplasty using the new da Vinci SP surgical platform (Intuitive Surgical Inc., Sunnyvale, CA), and to describe the approach through a mini-pfannenstiel incision.

METHODS

Data from a prospectively maintained single-institution database on all patients undergoing single-port robotic-assisted pyeloplasty between November 2018 and November 2019 were reviewed. Pyeloplasty was performed with the da Vinci SP system through a pure single site approach (except for the first patient). The initial procedures were performed through a midline incision and the technique evolved to a mini-pfannenstiel incision. Patient demographics, intraoperative data, post-operative data and surgical outcomes were collected.

RESULTS

Overall, 10 patients were included and underwent the procedure without intraoperative complications or conversion to an alternate approach. The patients' ages ranged between 11 and 75 years. Mean operative time was 166 minutes (interquartile range [IQR] 146-181) and EBL was minimal. Pfannenstiel incision was performed for 6 patients and 4 patients had a vertical midline incision. The only complication recorded was a postoperative urinary tract infection treated with antibiotics. The median postoperative hospital stay was 21 hours (7-24). Postoperative pain management after discharge was managed exclusively with non-opioid medication. Overall success rate defined as the absence of pain and renal obstruction on post-operative imaging at 3 months after surgery was 100%.

CONCLUSION

Single-port robotic-assisted laparoscopic pyeloplasty is a safe and feasible procedure through a mini-pfannenstiel incision.

One week stenting after pediatric laparoscopic pyeloplasty; is it enough?

INTRODUCTION

The use of ureteric stents for urinary diversion after pediatric dismembered pyeloplasty and its duration remain debatable. Classically, an indwelling Double J ureteric stent has to be left for 4-6 weeks. However, such a duration is not free of stent-related complications, in addition to the need to remove it under general anesthesia in the pediatric age group.

OBJECTIVES

This study aims to evaluate the outcome of short-term stenting after laparoscopic pyeloplasty in pediatric sector.

METHODS

A prospective randomized study of 37 children (less than 16 years-old) with pelvi-ureteric junction obstruction (PUJO) were managed by laparoscopic pyeloplasty by the same surgeon in the period between April 2015 and September 2017. In group A (18 patients), the DJ was removed after 4 weeks under general anesthesia, while in group B (19 patients), the DJ was fixed to the urethral catheter by a stitch, and it was removed with the urethral catheter after one week in the outpatient office. All patients were followed regularly for symptomatic improvement. Urine culture and sensitivity was done 1 month postoperatively. Abdominal ultrasound was done at 3, 6, 12 months and annually thereafter, while renal isotope scanning was done after 6 months.

RESULTS

There were no significant differences between both groups regarding operative duration, postoperative leakage, hospital stay, early postoperative complications. Both groups improved after pyeloplasty with no significant differences regarding symptoms, follow-up ultrasound, and renal scanning. The incidence of irritative symptoms and need for anticholinergics after catheter removal as well as urinary tract infection after 1 month were significantly higher in group A (P-value: 0.004 and 0.029, respectively) (Table).

DISCUSSION

To the authors knowledge, this is the first prospective controlled randomized study comparing short-term stenting with the classic 4 weeks stenting after laparoscopic pyeloplasty in the pediatric age group. In addition, the used technique of stenting not only allows stent removal on outpatient basis without anesthesia but also benefits from the pre-operative retrograde study so as not to miss any associated pathology in the ureter.

CONCLUSION

Short-term ureteric stenting after laparoscopic pyeloplasty in pediatric age group is safe and not inferior to the standard 4-week stenting. It also avoids the stent-related complications.

To evaluate the minimum number of renal scans required to follow pediatric patient postpyeloplasty

The aim of the study is to evaluate the minimum number of renal scans required to follow pediatric patients postpyeloplasty. We prospectively reviewed the renal scans of 145 children with unilateral pelvi-ureteric junction obstruction who underwent dismembered pyeloplasty. Patients were then divided into four groups based on preoperative split renal function. All patients were followed with renal scan and ultrasound for minimum of 4 years. Renal scan and ultrasound were done after stent removal at 3, 6, and 12 months and then yearly after surgery. Drainage pattern (T1/2) was seen in all groups, except in patients where there was no comment on drainage pattern. Statistical analysis was performed using the Friedman ANOVA and Wilcoxon signed-ranks test as a post hoc test with Bonferroni correction and Kruskal–Wallis test with Mann–Whitney U-test as a post hoc test with Bonferroni correction. On comparison of the pattern of drainage with time in Groups 1–4, it was found that there was no significant difference with time in Group 1. Then, further, using Wilcoxon signed-rank test as post hoc test for Friedman ANOVA, Group 2 showed statistically significant difference in drainage pattern in scans between 6 months and 1 year, Group 3 showed statistically significant difference in drainage pattern in scans between 3 months and 1 year, and Group 4 showed statistically significant difference in drainage pattern in scans done between 3 and 6 months (P < 0.05). Minimum of three renal scans were required for paediatric patients post pyeloplasty at 3 months, 6 months and 1 year in the follow up period.

Successful outcomes in laparoscopic pyeloplasty using knotless self-anchoring barbed suture in children

INTRODUCTION

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in children has gained increasing importance over the last decade. Intracorporeal knot tying still remains a technical challenge for the surgeon. Self-anchoring suture incorporates a new concept for tissue approximation and reduces intracorporeal knot tying problems. There are very few reports on self-anchoring knotless suture and its application for laparoscopic pyeloplasty in children. We present our results of a series of consecutive children undergoing laparoscopic pyeloplasty with knotless barbed sutures.

MATERIAL AND METHOD

We prospectively evaluate 15 consecutive patients who underwent laparoscopic pyeloplasty with knotless barbed sutures (V-Loc^TM, Covidien) for ureteropelvic anastomosis. The decision of the operation was given by pediatric nephrology-urology-radiologic imaging diagnostic team, and all patients were operated by a single surgeon. Pyeloplasty was performed without pelvic reduction, and the anastomosis was made by barbed sutures using running fashion.

RESULTS

The mean age of the patients were 5.39 (3 months-17 years). Two cases had undergone a right-sided pyeloplasty, and thirteen had undergone a left-sided pyeloplasty. The duration of the operative procedure was 60-110 min. Neither intraoperative nor postoperative complication was encountered in any of the cases. Patients were followed by ultrasonographic evaluation. The anteroposterior diameter (AP) diameter of renal pelvis and hydronephrosis grade Society for Fetal Urology (SFU) are significantly different when compared with pre-operative and postoperative period (p = 0.001 and p = 0.001, respectively). Owing to the renal parenchymal thickness change by age pre-operative and postoperative thickness comparison is adjusted by age, because age is considered as a covariate (confounder variable). We observed statistically significant (p = 0.003) difference in parenchymal thickness in all cases. Follow-up periods of the 15 consecutive pediatric pyeloplasty cases were 6-54 months.

CONCLUSION

In the present study, successful outcome of the laparoscopic pyeloplasty using barbed suture was shown for the first time in children in literature. We believe that successful outcome of laparoscopic pyeloplasty could be achieved by eliminating knots and less manipulation on the wound edge also minimizes tissue injury during the procedure.

Laparoscopic Disconnected Pyeloplasty to Treat Ureteropelvic Junction Obstruction (UPJO) in Children

Background

The aim of this study was to assess the safety and clinical effectiveness of laparoscopic disconnected pyeloplasty in treating ureteropelvic junction obstruction (UPJO) in children.

Material/Methods

We retrospectively analyzed the clinical data of 122 young children with UPJO treated from February 2015 to February 2018 at our hospital. According to the surgery type, the patients were divided into 2 groups: a laparoscopic surgery group (group A, n=69) and a traditional open surgery group (group B, n=53).

Results

The success rate of laparoscopic disconnected pyeloplasty was 100%, and none of the patients were converted to open surgery. The mean duration of use of painkillers was 27.6±11.3 h in group A and 58.2±18.2 h in group B (p=0.012), the postoperative hospital stay was 7.8±1.5 days in group A and 11.5±2.6 days in group B (p=0.041), and the length of the incision was 1.5±0.4 cm in group A and 5.2±1.1 cm in group B (p=0.007). The incidence rate of poor surgical wound healing was 0% in group A and 7.5% in group B (p=0.020). The incidence rate of ureteral stricture was 4.3% in group A and 3.8% in group B (p=0.874) during follow-up. The 1-year follow-up showed that both the anterior and posterior diameters and glomerular filtration rate were significantly improved from the preoperation period.

Conclusions

Laparoscopic disconnected pyeloplasty to treat UPJO in young children has the same early clinical effectiveness and safety as open surgery, and this procedure has the advantages of minimal trauma, quick recovery, and good cosmetic effect.

Surgical approaches for treatment of ureteropelvic junction obstruction - a systematic review and network meta-analysis

Background

Multiple surgical treatment options are available for the treatment of ureteropelvic junction obstruction (UPJO). The aim of this study is to compare the most frequently used technics in a comprehensive network approach.

Methods

A systematic literature search of the EMBASE, MEDLINE and COCHRANE libraries was conducted in January 2018. Publications were included that evaluated at least two of the following surgical techniques: open pyeloplasty (OP), endopyelotomy (EP), laparoscopic (LP) and robot assisted pyeloplasty (RP). Main outcomes were operative success, complications, urinary leakage, re-operation, transfusion rate, operating time, and length of stay. Network meta-analyses with random effects models simultaneously assessed effectiveness of all surgical techniques.

Results

A total of 26 studies including 3143 patients were analyzed. Compared with RP, EP and LP showed lower operative success rates (EP: OR = 0.09, 95%CI:0.05–0.19; p < 0.001; LP: OR = 0.51, 95%CI:0.31–0.84; p = 0.008). Compared with OP, LP and RP had lower risk for complications (LP: OR = 0.62; 95%CI:0.41–0.95; p = 0.027; RP: OR = 0.41; 95%CI:0.22–0.79; p = 0.007). Compared with RP, no significant differences were detected for urinary leakage or re-operation, transfusion rates. Compared with EP, RP yielded longer operating time (mean = 102.87 min, 95%CI:41.79 min–163.95 min, p = < 0.001). Further significant differences in operating times were detected when comparing LP to EP (mean = 115.13 min, 95%CI:65.63 min–164.63 min, p = < 0.001) and OP to EP (mean = 91.96 min, 95%CI:32.33 min–151.58 min, p = 0.003).

Conclusions

Multiple surgical techniques are available for treatment of UPJO. RP has the highest rates of operative success and as well as LP lower complication rates than OP. Although surgical outcomes are worse for EP, its operating time is shorter than OP, RP, and LP. Surgeons should consider these findings when selecting the optimal treatment method for individual patients.

Comparison of 30-day postoperative outcomes of open and minimally invasive pyeloplasty utilizing the prospective National Surgical Quality Improvement Program-Pediatric database

INTRODUCTION

Open pyeloplasty (OP) has traditionally been the standard for the operative management of ureteropelvic junction obstruction in children. With advances in minimally invasive pyeloplasty (MIP) techniques, it is quickly becoming a popular alternative in both adult and pediatric population.

OBJECTIVE

To evaluate the differences in outcomes between MIP and OP for the surgical correction of ureteropelvic junction obstruction in children.

STUDY DESIGN

Data were obtained from the pediatric National Surgical Quality Improvement Program 2012-2017. We identified 1280 patients who underwent MIP and 1190 patients who underwent OP between 2012 and 2017. Propensity score matching was utilized to adjust for baseline differences. Univariate and multivariable regression were performed to assess odds of complications and procedure-related readmission.

RESULTS

Patients who underwent OP had a significantly decreased operative time (192.42 vs 142.00 min, p < 0.001) compared to MIP. There was no significant difference in the rates of overall peri-operative complications (3.7% [MIP] vs 2.4% [OP] p = 0.397). On multivariable analysis, patients undergoing OP had a lower risk of procedure-related readmission (odds ratio [OR] 0.404, 95% confidence interval [CI] 0.157-0.951, p = 0.046) than MIP. In a multivariable linear regression model, the risk of having any postoperative complication, regardless of surgical approach, decreased with increasing patient age (OR 0.945, 95% CI 0.893-0.996, p = 0.037).

DISCUSSION

Although recent small, retrospective institutional studies have found decreased hospitalization time of MIP as compared to OP, in our large prospective database, we found no such association. While some studies suggest a higher rate of wound complications in the OP group, this was not reproduced in our study as well. MIP was, in fact, associated with higher rate of readmissions as compared to the OP group, which may act as a surrogate of long-term complications in these patients.

CONCLUSION

MIP offers an alternative to OP in the pediatric population with similar rates of peri-operative complications. However, our study shows decreased odds of procedure-related readmission in OP, which may serve as a surrogate for less postoperative complications in these patients.

Endoscopic Balloon Dilatation in the Treatment of Benign Ureteral Strictures: A Meta-Analysis and Systematic Review

BACKGROUND AND PURPOSE

Although balloon dilatation is one of the main endoscopic procedures used to treat benign ureteral strictures, its precise efficacy remains controversial. We aimed to identify, combine, and analyze existing published data to ascertain the efficacy of endoscopic balloon dilatation for benign ureteral strictures.

METHODS

In December 2018, a literature search was performed using Medline, Embase, and Web of Science databases. We included reports in which the study population consisted of patients who underwent endoscopic balloon dilatation for the treatment of benign ureteral strictures. Technical, short-term, and long-term success rates (expressed as mean ± standard error) were adopted as the outcome measures.

RESULTS

Using our search strategy, a total of 19 studies (all series reports) were included for analysis. Using a random-effects model, the pooled technical success rate of endoscopic balloon dilatation for benign ureteral strictures was found to be 89% ± 4%. Furthermore, the short-term success rate (i.e., 3 months after surgery) was 60% ± 10%, and the long-term success rate (i.e., 6-12 months after surgery) was 54% ± 14%. In the subgroup analysis, the success rate of endoscopic balloon dilatation for ≤2-cm benign ureteral strictures was significantly higher than that for >2-cm ones (odds ratio [OR]: 0.13; 95% confidence interval [CI]: 0.05-0.35). In addition, the success rate in cases with strictures of onset timing ≤3 months was relatively higher than that in cases with strictures of onset timing >3 months (OR: 0.46; 95% CI: 0.15-1.43).

CONCLUSION

Our study indicates that endoscopic balloon dilatation has a high success rate in the treatment of benign ureteral strictures with length ≤2 cm and onset timing ≤3 months. However, there is still no consensus on balloon type, dilatation pressure, expansion number, postoperative ureteral stent type, and stent retention time for the balloon dilatation technique.

Balloon dilation for failed pyeloplasty in children?

Objective:

Pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). However, the failure rate of pyeloplasty is as high as 10% and repeat pyeloplasty is more difficult. This study aimed to evaluate the efficacy of balloon dilatation for failed pyeloplasty in children.

Materials and Methods:

Between 2011 and 2017, 15 patients, aged 6 months to 14 years, were treated with balloon dilation for restenosis of UPJO after a failed pyeloplasty. Ultrasound and intravenous urography were used to evaluate the primary outcome. Success was defined as the relief of symptoms and improvement of hydronephrosis, which was identified by ultrasound at the last follow-up.

Results:

All patients successfully completed the operation, 13 patients by retrograde approach and 2 patients by antegrade approach. Thirteen patients were followed for a median of 15 (4 to 57) months and 2 patients were lost to follow-up. Resolution of the hydronephrosis was observed in 5 cases. The anteroposterior diameter (APD) of the pelvis decreased by an average of 12.4 ± 14.4mm. Eight patients needed another surgery. The average postoperative hospital stay was 1.78 ± 1.4 days. Two patients experienced fever after balloon dilation. No other complications were found.

Conclusions:

Balloon dilatation surgery is safe for children, but it is not recommended for failed pyeloplasty in that group of patients, owing to the low success rate.

Learning robotic pyeloplasty without simulators: an assessment of the learning curve in the early robotic era

OBJECTIVE

To analyze our experience and learning curve for robotic pyeloplasty during this robotic procedure.

METHODS

Ninety-nine patients underwent 100 consecutive procedures. Cases were divided into 4 groups of 25 consecutive procedures to analyze the learning curve.

RESULTS

The median anastomosis times were 50.0, 36.8, 34.2 and 29.0 minutes (p=0.137) in the sequential groups, respectively. The median operative times were 144.6, 119.2, 114.5 and 94.6 minutes, with a significant difference between groups 1 and 2 (p=0.015), 1 and 3 (p=0.002), 1 and 4 (p<0.001) and 2 and 4 (p=0.022). The mean hospital stay was 7.08, 4.76, 4.88 and 4.20 days, with a difference between groups 1 and 2 (p<0.001), 1 and 3 (p<0.001) and 1 and 4 (p<0.001). Clinical and radiological improvements were observed in 98.9% of patients. One patient presented with recurrent obstruction.

CONCLUSIONS

Our results demonstrate a high success rate with low complication rates. A significant decrease in hospital stay and surgical time was evident after 25 cases.

Outcomes after Robotic-assisted Pyeloplasty in Patients Presenting with Pain Versus Nonpain Presenting Symptoms

OBJECTIVE

To assess the impact of presenting symptom or incidental finding on symptomatic and radiographic outcomes after robotic-assisted pyeloplasty (RAP).

METHODS

We retrospectively reviewed the records of 143 patients at our institution who received pyeloplasty from 2001-2017. Patients without both pre- and postoperative radiographic data were excluded. Patients were grouped by primary presenting symptom into either pain at presentation (pain) or nonpain primary presenting symptom, including incidental findings (nonpain). Primary outcomes were persistence of postoperative symptoms and improvement in diuretic renogram half-times.

RESULTS

The study inclusion criteria was met by 105 patients. Pain was the most common presenting symptom (70.0%), followed by incidental finding (10.5%), infection (7.6%), hematuria (4.8%), hypertension (2.8%), elevated creatinine (2.8%), and nausea (1.0%). Patients with nonpain presentations were significantly more likely to have postoperative symptoms (P = .04), and less likely to improve on diuretic renogram (P = .03). Incidental presentation was found to be associated with greater likelihood of persistent postoperative symptoms compared with other presentations (36.3% vs 8.5%, P = .02).

CONCLUSION

Ureteropelvic junction obstruction (UPJO) patients presenting with pain, experience better symptom and radiographic improvement following RAP compared with patients presenting without pain. Incidental UPJO was the most common nonpain presentation and is associated with less symptomatic and radiographic benefit after RAP. These findings will help reconstructive urologists counsel patients with UPJO regarding outcomes of RAP.

Outcomes of infants undergoing laparoscopic pyeloplasty: A single-center experience

PURPOSE:

The aim of this study was to evaluate the outcomes of laparoscopic pyeloplasty in children less than 12 months of age.

MATERIALS AND METHODS:

The records of 20 infants, who had pelviureteric junction obstruction and subsequently underwent LP from January 2013 to November 2016 with at least 1 year of follow-up, were retrospectively reviewed. Patients demographics, the results of preoperative and postoperative imaging studies, perioperative details, complications, and results were noted.

RESULTS:

The mean age of 20 infants was 4.75 months. The gender of cases was 5 females (25%) and 15 males (75%). Of that, 13 (65%) laparoscopic pyeloplasties were in left side and 7 (35%) were in right side. No cases needed open conversation. Aberrant crossing vessel was observed in three patients (15%). The mean operation time was 79.35 min (45-128 min). The mean hospital stay was 2.9 ± 0.308 days (2-3 days). There were complications in three children (15%); two patients developed stent migration and one child had fever over 38°. Three children with complications did not require a second intervention. In one child, the kidney was non-functioning in follow-up and nephrectomy was performed. The anteroposterior diameter significantly reduced. Preoperative mean value was 24.305 ± 5.6157 and postoperative mean value was 15.40 ± 6.030 (p = 0.000, p < 0.05). There was a significant degree of improvement in renal split function for all patients. Preoperative mean values were 45.53 ± 11.512, while postoperative values were 47.850 ± 13.347 (p = 0.029, p < 0.05).

CONCLUSION:

Although there are doubts about the reliability and efficacy of results for pyeloplasty in children less 12 months, many studies including this study show that laparoscopic pyeloplasty is an effective and reliable method for infants.

Laparoscopic Dismembered Pyeloplasty in a Solitary Kidney with Intrarenal Pelvis: Two Challenges in One Case

Laparoscopic pyeloplasty (LP) for ureteropelvic junction obstruction (UPJO) is one of the most appropriate surgical techniques to achieve the optimal goal of minimally invasive surgery. However, urologists hesitate to use the laparoscopic approach in UPJO with solitary kidney or intrarenal pelvis. There are a few published studies on laparoscopic pyeloplasty cases in intrarenal pelvis. However, to the best of our knowledge, the present case is the first in the literature in terms of intrarenal pelvis in a solitary kidney. Generally, YV plasty is the accepted technique instead of dismembered pyeloplasty in UPJO with small or intrarenal pelvis. However, in this report, we showed that dismembered LP can be performed with good results in intrarenal pelvis UPJO, even if it is in the solitary kidney.

Current status of robotic surgery in urology

As a result of ergonomics, optimal magnification of the operative field, surgeon dexterity, and precision of surgical manipulation, robotic technology has been shown to overcome many difficulties associated with pure laparoscopy. With the recent expansion of robot-assisted surgery in the field of urology and following the success of robot-assisted prostatectomy and robot-assisted partial nephrectomy, robot-assisted surgery is being applied to treat many other genitourinary diseases, such as bladder cancer and ureteropelvic junction obstruction. The aim of the present review is to discuss the role of robotic surgery in urology and summarize recent developments in the field of urologic robotic surgery.

The Comparative Effectiveness of Treatments for Ureteropelvic Junction Obstruction

OBJECTIVE

To examine the effectiveness of the 3 primary treatments for ureteropelvic junction obstruction (ie, open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy) as assessed by failure rates.

MATERIALS AND METHODS

Using MarketScan data, we identified adults (ages 18-64 years) who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was failure (ie, need for a secondary procedure). We fit a Cox proportional hazards model to examine the effects of different patient, regional, and provider characteristics on treatment failure. We then implemented a survival analysis framework to examine the failure-free probability for each treatment.

RESULTS

We identified 1125 minimally invasive pyeloplasties, 775 open pyeloplasties, and 1315 endopyelotomies with failure rates of 7%, 9%, and 15%, respectively. Compared with endopyelotomy, minimally invasive pyeloplasty was associated with a lower risk of treatment failure (adjusted hazards ratio [aHR] 0.52; 95% confidence interval [CI], 0.39-0.69). Minimally invasive and open pyeloplasties had similar failure rates. Compared with open pyeloplasty, endopyelotomy was associated with a higher risk of treatment failure (aHR 1.78; 95% CI, 1.33-2.37). The average length of stay was 2.7 days for minimally invasive pyeloplasty and 4.2 days for open pyeloplasty (P <.001).

CONCLUSION

Endopyelotomy has the highest failure rate, yet it remains a common treatment for ureteropelvic junction obstruction. Future research should examine to what extent patients and physicians are driving the use of endopyelotomy.

Cost Analysis of Treatments for Ureteropelvic Junction Obstruction

BACKGROUND AND PURPOSE

Ureteropelvic junction obstruction is a common urologic condition that accounts for approximately $12 million in inpatient spending annually. Few studies have assessed the costs related to treatment. We sought to examine the cost of care for patients treated for ureteropelvic junction obstruction.

PATIENTS AND METHODS

We used the MarketScan^® database to identify adults from 18 to 64 years old treated with minimally invasive pyeloplasty, open pyeloplasty, and endopyelotomy for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was total expenditures related to the surgical episode, defined as the period from 30 days prior until 30 days after the index surgery. We fit a multinomial linear regression model to evaluate cost of the surgical episode, adjusting for age, gender, comorbidity, benefit plan type, and region of residence.

RESULTS

We identified 1251 endopyelotomies, 717 open pyeloplasties, and 1048 minimally invasive pyeloplasties. The adjusted mean costs were $16,379 for endopyelotomy, $22,421 for open pyeloplasty, and $22,843 for minimally invasive pyeloplasty (p < 0.0001, ANCOVA). Both open and minimally invasive pyeloplasties were more costly than endopyelotomy (both p < 0.0001, comparison between groups). However, the cost of open and minimally invasive pyeloplasties was similar (p = 0.57, comparison between groups).

CONCLUSIONS

Among the three treatments, endopyelotomy was the least expensive in the immediate perioperative period. Open and minimally invasive pyeloplasties were similar in cost, but both more expensive than endopyelotomies. The similar cost between the two pyeloplasty approaches provides additional evidence that minimally invasive pyeloplasty should be considered the standard treatment for ureteropelvic junction obstruction.

Variation in the Use of Open Pyeloplasty, Minimally Invasive Pyeloplasty, and Endopyelotomy for the Treatment of Ureteropelvic Junction Obstruction in Adults

BACKGROUND AND PURPOSE

Ureteropelvic junction obstruction is a common condition that can be treated with open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy. While all these treatments are effective, the extent to which they are used is unclear. We sought to examine the dissemination of these treatments.

PATIENTS AND METHODS

Using the MarketScan^® database, we identified adults 18 to 64 years old who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was ureteropelvic junction obstruction treatment (i.e., open pyeloplasty, minimally invasive pyeloplasty, endopyelotomy). We fit a multilevel multinomial logistic regression model accounting for patients nested within providers to examine several factors associated with treatment.

RESULTS

Rates of minimally invasive pyeloplasty increased 10-fold, while rates of open pyeloplasty decreased by over 40%, and rates of endopyelotomy were relatively stable. Factors associated with receiving an open vs a minimally invasive pyeloplasty were largely similar. Compared with endopyelotomy, patients receiving minimally invasive pyeloplasty were less likely to be older (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.95, 0.97) and live in the south (OR 0.52; 95% CI, 0.33, 0.81) and west regions (OR 0.57; 95% CI 0.33, 0.98) compared with the northeast and were more likely to live in metropolitan statistical areas (OR 1.52; 95% CI 1.08, 2.13).

CONCLUSIONS

Over this 9-year period, the landscape of ureteropelvic junction obstruction treatment has changed dramatically. Further research is needed to understand why geographic factors were associated with receiving a minimally invasive pyeloplasty or an endopyelotomy.

Laparoscopic Pyeloplasty: Always Dismembered?

OBJECTIVE

To compare three laparoscopic surgical techniques for the treatment of ureteropelvic junction obstruction (UPJO), assessing their difficulty, operating time, effectiveness, and complications.

MATERIALS AND METHODS

The clinical histories of 54 patients with UPJO who underwent a laparoscopic procedure between June 2003 and September 2013 were reviewed. Anderson-Hynes (A-H) pyeloplasty was performed on 34 patients, nondismembered pyeloplasty on 11 cases (8 Y-V Foley plasty and 3 Fenger plasty), and cephalad vascular displacement or Hellström technique (HT) on 9 patients. The patients were selected for the different techniques depending on the findings during the procedures, according to renal pelvic size and the presence of crossing vessels. We compared the techniques according to intraoperative and postoperative outcomes. Complications were interpreted following the Clavien-Dindo classification. The success rate was defined as the absence of clinical symptoms and normal diuretic renography. Analysis of variance and chi-square tests were used for the statistical analysis.

RESULTS

Mean follow-up was 55.58 months. The success rate achieved was 88.5% for A-H pyeloplasty, 90.9% for nondismembered pyeloplasty, and 100% for HT (p > 0.05). HT was the least time-consuming: 124 ± 30 vs 202 ± 44 minutes of A-H pyeloplasty and 147 ± 27 minutes of nondismembered plasty (p < 0.005). Mean hospital stay was 6.7 ± 1.4 days for A-H pyeloplasty, 6.6 ± 2 days for nondismembered pyeloplasty, and 3.42 ± 1.5 days for HT (p < 0.05). The postoperative complication rate was 21.1% for A-H pyeloplasty, 18.8% for nondismembered pyeloplasty, and 12.5% for HT (p > 0.05). None of the cases required open surgery, and urinary fistula was the most frequent complication.

CONCLUSION

Intraoperative observation of ureteropelvic junction allows selecting cases to undergo nondismembered pyeloplasty techniques, achieving similar results to A-H pyeloplasty, reducing operating time, complication rate, and hospital stay.

Robotic pyeloplasty: Initial experience of a single UK centre

Objective:

We present our experience and outcomes at a single UK robotic centre of robotic-assisted laparoscopic dismembered pyeloplasty for the treatment of pelvo-ureteric junction obstruction (PUJO).

Materials and methods:

Between July 2009 and July 2013, 20 robotic-assisted transperitoneal laparoscopic pyeloplasties were performed by four surgeons. Data were obtained from patient case notes, patient charts, and radiographic reports.

Results:

A total of 20 robot-assisted laparoscopic dismembered pyeloplasties were performed in 11 men and nine women. Mean age at treatment was 37 years (range 16–75) with an average follow-up of 14 months (five to 24). The average console time was two hours: 8 minutes (1:30–3:30), mean drop in haemoglobin 0.67 g/dl (−3.5 to +1.3), mean change in serum creatinine −0.5 (−22 to +18). The average time to post-operative catheter removal was 1.64 days (one to two), to post-operative drain removal 2.43 days (two to three), and to discharge 2.8 days (two to four). The average time to stent removal was 6.1 weeks (six to eight). At the mean follow-up of 14 months no major perioperative complications had occurred and no patients were re-admitted within 30 days of operation. The success rate was 95%; one patient required a second procedure in the form of an open redo-pyeloplasty because of continued pain and radiographic evidence of continued obstruction.

Conclusions:

These results suggest that robotic-assisted laparoscopic pyeloplasty is a feasible treatment for PUJO in a UK centre. Low rates of morbidity, short post-operative stay and high success rates at our centre are comparable with other series. Longer follow-up of this cohort is needed to demonstrate durable and effective outcomes.

Laparoscopic stepwise-cut double initial stay suture pyeloplasty: our novel surgical technique

OBJECTIVE

To describe a novel surgical technique, laparoscopic stepwise-cut double initial stay suture (LASDISS) pyeloplasty for ureteropelvic junction obstruction (UPJO). Additionally, we evaluated the safety and short-term results.

MATERIALS AND METHODS

This was a nonrandomized study with a series of 6 patients with UPJO, operated on between March 2012 and August 2013. Perioperative and short-term outcomes were evaluated. In brief, a "T shape cut" was performed from the dilated pelvis to the ureter. The initial stay suture was placed between the lower edge of the pelvis and the distal end of the spatulated anterolateral part of the ureter. The pelvis was closed with a continuous suture starting from the opened upper edge of the pelvis that was secured after leaving enough space for ureteral anastomosis. The second initial stay suture was placed after passing the ureter and pelvis two times. The dilated part of the renal pelvis and the stenotic segment were excised. A double-J stent was inserted. The remaining space between the two initial sutures was closed with these continuous sutures.

RESULTS

We performed the LASDISS pyeloplasty technique in all cases. Median operation time was 177 minutes (range, 100-290 minutes). Mean follow-up was 7.5 months (range, 3-18 months). The mean pre- and postoperative split renal function on diuretic renography was 33% (range, 25%-56%) and 42% (range, 30%-52%), respectively.

CONCLUSIONS

The LASDISS pyeloplasty surgical technique represents a safe and effective option in surgical treatment of UPJO.

Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction: long-term results

OBJECTIVE

To evaluate the long-term results of laparoscopic pyeloplasty in patients with secondary ureteropelvic junction obstruction after failed primary interventions.

METHODS

Between August 2000 and October 2012, transperitoneal dismembered laparoscopic pyeloplasty was carried out in 13 patients with a surgical history of failed prior surgical interventions. Perioperative outcomes as well as long-term results were assessed. These outcomes were compared with those of the same procedure carried out for primary ureteropelvic junction obstruction by a single surgeon during the same study period.

RESULTS

Laparoscopic transperitoneal pyeloplasty was completed successfully in all cases without converting to open surgery or requiring blood transfusion. The preoperative symptoms in 12 of 13 patients all disappeared soon after the operation. Asymptomatic severe hydronephrosis found in a 2-year-old boy reduced in size postoperatively. When comparing the primary with the secondary laparoscopic pyeloplasty carried out by the same surgeon, the mean operative time was longer (183 vs 241 min, P = 0.002), estimated blood loss was larger (33 vs 66 mL, P = 0.03) and the complication rate was higher (8.8% vs 22.2%, P = 0.01) in the secondary group. Success rates were 97.9% and 100% (P = 0.41) at a mean follow up of 25.9 and 40.0 months (P = 0.14) for the primary and secondary groups, respectively.

CONCLUSIONS

Laparoscopic pyeloplasty is an excellent option for patients who failed previous surgical management. This approach provides durable long-term outcomes comparable with those of primary treatment for ureteropelvic junction obstruction.

Robotic laparoscopic pyeloplasty

BACKGROUND AND OBJECTIVES

We aimed to assess the feasibility and outcomes of complex ureteropelvic junction obstruction cases submitted to robotic-assisted laparoscopic pyeloplasty.

METHODS

The records of 131 consecutive patients who underwent robotic-assisted laparoscopic pyeloplasty were reviewed. Of this initial population of cases, 17 were considered complex, consisting of either atypical anatomy (horseshoe kidneys in 3 patients) or previous ureteropelvic junction obstruction management (14 patients). The patients were divided into 2 groups: primary pyeloplasty (group 1) and complex cases (group 2).

RESULTS

The mean operative time was 117.3 ± 33.5 minutes in group 1 and 153.5 ± 31.1 minutes in group 2 (P = .002). The median hospital stay was 5.19 ± 1.66 days in group 1 and 5.90 ± 2.33 days in group 2 (P = .326). The surgical findings included 53 crossing vessels in group 1 and 5 in group 2. One patient in group 1 required conversion to open surgery because of technical difficulties. One patient in group 2, with a history of hemorrhagic rectocolitis, presented with peritonitis postoperatively due to a small colonic injury. A secondary procedure was performed after the patient had an uneventful recovery. At 3 months, significant improvement (clinical and radiologic) was present in 93% of cases in group 1 and 88.2% in group 2. At 1 year, all patients in group 2 showed satisfactory results. At a late follow-up visit, 1 patient in group 1 presented with a recurrent obstruction.

CONCLUSIONS

Robotic pyeloplasty appear to be feasible and effective, showing a consistent success rate even in complex situations. Particular care should be observed during the colon dissection in patients with previous colonic pathology.

The robotic-assisted laparoscopic pyeloplasty: gateway to advanced reconstruction

Robotic pyeloplasty is now commonly performed for children with ureteropelvic junction obstruction. Because surgical robotics is a tool that facilitates pyeloplasty and other reconstructive urologic operations, the indications for robotic-assisted laparoscopic pyeloplasty are the same as those for an open pyeloplasty but offer distinct advantages with respect to visualization, range of motion, and ease of laparoscopic suturing. In this review, the authors discuss the operative approach for robotic pyeloplasty in children and the extensions of the basic techniques to challenging clinical scenarios.

Passing from open to robotic surgery for dismembered pyeloplasty: a single centre experience

BACKGROUND

The treatment of symptomatic uretropelvic junction obstruction (UPJO) has evolved towards minimal invasive endourologic and laparoscopic techniques. Robotic assisted laparoscopic pyeloplasty has achieved outcomes comparable to those corresponding to open and laparoscopic techniques. The objective of this work is to demonstrate that the transition between open to robotic surgeries is straightforward. We analysed retrospectively "our initial results" in robotic assisted UPJ reconstruction procedures. Technical and convalescence aspects for 17 reconstructive robotic procedures performed by 2 surgeons in a 5 years period have been evaluated. Success consisted of no postoperative symptoms, no evidence of obstruction on mercaptoacetyltriglycine-3 diuretic renal scan or computed tomography (CT) and non-further treatment.

STATISTICS

mean ± standard deviation, median and range.

FINDINGS

From 17 patients who underwent Da Vinci Robot procedure, 15 followed the complete treatment (2 were converted to laparotomy). Two patients had post-operative urine leakage; the stent was changed under sedation without further sequelae. The mean operative time was 189 minutes. The average hospital stay was 4 days. The average follow-up was 25 months. There was only one patient with UPJ stenosis at 6 months and he was treated by balloon dilation. All patients were followed with MAG 3 lasix renal scan, CT or urography. Except the patient with recurrent stenosis, all patients were asymptomatic without objective evidence of obstruction at the present time.

CONCLUSIONS

Robotic pyeloplasty technique is feasible and gives good results without previous laparoscopic experience.

Laser endoureterotomy and endopyelotomy: an update

PURPOSE

Although minimally invasive approach is one of the first-line treatment choices for ureteral strictures, there are still controversies on the ideal method to treat this entity. The objective of this update was to define the level of evidence around endoscopic treatment of ureteropelvic junction (UPJ) and ureteral strictures.

METHODS

We reviewed the current available literature on the PubMed database from the last decade up to May 2014 on laser endoureterotomy and endopyelotomy.

RESULTS

The level of evidence for the endoscopic treatment of UPJ and ureteral strictures is low. Despite this, it appears that endoureterotomy and endopyelotomy performed mainly with Ho:YAG laser achieve good success rates with minimal perioperative morbidity.

CONCLUSIONS

Laser endoureterotomy and endopyelotomy should be considered a reasonable treatment option in selected patients.

Prospective randomized study to evaluate the feasibility and outcome of transmesocolic laparoscopic pyeloplasty and compare it with retrocolic laparoscopic pyeloplasty in pediatric and adolescent patients

OBJECTIVE

This prospective randomized study was designed to evaluate the feasibility and outcome of transmesocolic laparoscopic pyeloplasty (TMP) and compare it with retrocolic laparoscopic pyeloplasty (RLP) in pediatric and adolescent patients.

MATERIALS AND METHODS

Between September 2006 to May 2012, data of pediatric and adolescent patients undergoing laparoscopic pyeloplasty were recorded in a prospective manner. Data included age, pelvic volume, presence of stones, aberrant vessels, operative time, analgesics requirement and time to accept oral feeds and drain removal. Patients with left side pelviureteric junction obstruction with any size of pelvic volume, with or without renal stones and aberrant vessels were included in the study. Patients were assigned into two groups by simple randomization technique. A total of 38 TMP and 41 left sided RLP were performed. Median follow-up period for transmesocolic group was 12.5 months (9.5-62 months) and 14 months (8-66 months) for retro colic group. Outcome for this study was adequate drainage on renal scan, improvement in symptom and or resolution of hydronephrosis on ultrasound. Statistical analysis was performed using the Mann-Whitney test.

RESULTS

The mean patient age was 8.73 years in RLP and 7.73 years in TMP. In RLP group the mean operative time was 75.84 min (time from port insertion to pyeloplasty) and 135.4 min (total operative time) while it was 44.82 min and 104.82 min respectively in TMP group. Compared with classic RLP, TMP cases showed a significant reduction in operative time.

CONCLUSIONS

The transmesocolic approach for left sided pyeloplasty enables a shorter operative time even in the presence of large pelvis, aberrant vessel and stones without increasing morbidity in comparison to RLP approach.

Robotic-assisted laparoscopic approaches to the ureter: Pyeloplasty and ureteral reimplantation

INTRODUCTION AND OBJECTIVES

The benefits of robotic surgery when compared to standard laparoscopy have been well established, especially when it comes to reconstructive procedures. The application of robotic technology to laparoscopic pyeloplasty has reduced the steep learning curve associated with the procedure. Consequently, this has allowed surgeons who are less experienced with laparoscopy to offer this treatment to their patients, instead of referring them to centers of excellence. Robotic pyeloplasty has also proved useful for repairing secondary UPJO, a procedure which is considered extremely difficult using a conventional laparoscopic approach. Finally, the pursuit of scarless surgery has seen the development of laparoendoscopic single site (LESS) procedures. The application of robotics to LESS (R-LESS) has also reduced the difficulty in performing conventional LESS pyeloplasty. Herein we present a literature review with regards to robotic-assisted laparoscopic pyeloplasty. We also discuss the benefits of robotic surgery with regards to reconstruction of the lower urinary tract.

MATERIALS AND METHODS

A systematic literature review was performed using PubMed to identify relevant studies. There were no time restrictions applied to the search, but only studies in English were included. We utilized the following search terms: Ureteropelvic junction obstruction and laparoscopy; laparoscopic pyeloplasty; robotic pyeloplasty; robotic ureteric reimplantation; robotic ureteroneocystostomy; robotic boari flap; robotic psoas hitch.

RESULTS

There has been considerable experience in the literature with robotic pyeloplasty. Unfortunately, no prospective randomized studies have been conducted, however there are a number of meta analyses and systematic reviews. While there are no clear benefits when it comes to surgical and functional outcomes when compared to standard laparoscopic pyeloplasty, it is clear that robotics makes the operation easier to perform. There is also a benefit to the robotic approach when performing a redo-pyeloplasty. Robotic pyeloplasty has also been applied to the pediatric population, and there may be a benefit in older children while in very young patients, retroperitoneal open pyeloplasty is still the gold standard. In the field of single incision surgery R-LESS is technically easier to perform than conventional LESS. However, the design of the current robotic platform is not completely suited for this application, limiting its utility and often requiring a larger incision. Optimized R-LESS specific technology is awaited. What is clear, from a number of analyses, is that robotic pyeloplasty is considerably more expensive than the laparoscopic approach, largely due to costs of instrumentation and the capital expense of the robot. Until cheaper robotic technology is available, this technique will continue to be expensive, and a cost-benefit analysis must be undertaken by each hospital planning to undertake this surgery. Finally, the benefits of upper tract reconstruction apply equally to the lower tract although there is considerably less experience. However, there have been a number of studies demonstrating the technical feasibility of ureteral reimplantation.

CONCLUSIONS

Robotic-assisted laparoscopic pyeloplasty is gaining popularity, likely due to the shorter learning curve, greater surgeon comfort, and easier intracorporeal suturing. This has allowed more surgeons to perform the procedure, improving accessibility. Robotic technology is also beneficial in the field of LESS. Nevertheless, the procedure still is not as cost-effective as the conventional laparoscopic approach, and until more affordable robotic technology is available, it will not be universally offered.

Preliminary experience with laparoscopic Foley's YV plasty for ureteropelvic junction obstruction in children

INTRODUCTION:

Laparoscopic dismembered pyeloplasty is an acceptable option for ureteropelvic junction (UPJ) obstruction in the paediatric population. We compared our results of laparoscopic dismembered and non-dismembered Foley's YV pyeloplasty.

MATERIALS AND METHODS:

Children presenting with hydronephrosis secondary to UPJ obstruction formed the study group. Foley's YV plasty was planned whenever it was observed that a tension free dismembered pyeloplasty was not possible in spite of all possible manoeuvres. Children were followed up for urinary infection, and renogram was repeated after 3 months.

RESULTS:

During the study period, 108 children (63 male and 45 female) with a mean age of 4.94 ± 2.78 years underwent laparoscopic dismembered pyeloplasty and the remaining 11 children (5 male and 6 female) with a mean age of 4.00 ± 1.776 years underwent laparoscopic Foley's YV plasty. There were no major peri-operative complications noted and conversion to open was not necessary in any child. Renogram done at 3 months post-operatively showed good drainage and improvement of renal function.

CONCLUSIONS:

Laparoscopic Foley's YV pyeloplasty is a safe and effective technique in appropriately selected cases of primary UPJ obstruction in children.

[Salvage laparoscopic pyeloplasty in the worst case scenario: after failed open repair and endoscopic salvage]

OBJECTIVES

We present the video of a laparoscopic correction of a left ureteropelvic junction obstruction in a patient who has already undergone previous surgical open pyeloplasty and subsequent acucise for failure of the first surgery. At 8 years after the second surgery, the patient showed a recurrence of the obstruction of the left ureteropelvic junction.
 It was decided to perform the retroperitoneal laparoscopic correction of the obstruction.


MATERIALS AND METHODS

With the patient placed in a 90° flank position, 4 trocars are placed in the retroperitoneum space by the Hasson tecnique.
 After the creation of the retroperitoneum space, the Gerota's fascia is opened. The posterior layer of the Gerota's fascia appears very thickened at the level of the lower pole of the kidney and is very adherent with the surrounding structures, in particular the psoas muscle.
 Gerota's fascia is incised and removed from the previous surgery and the psoas muscle is identified. The distal lumbar ureter is tenaciously anchored to the psoas muscle. The lower pole of the kidney is freed from the adhesions of the previous surgery. The proximal ureter is hardly isolable for the presence of fibrosis. The renal pelvis is fixed to the psoas due to fibrotic tissue that is cut with scissors. Once the pelvis and the ureter are separated from the psoas, the surgery proceeds with the liberation of the pelvis from the adipose tissue and fibrosis that surround it. The pieloureteral obstruction is not easily identifiable. The renal pelvis is opened at the level of the ureteral junction, the ureter is spatulated on its medial side. The scar tissue is removed until well vascularized tissue is seen. The anastomosis between the ureter and pelvis is performed with 2 semicontinuous running sutures. Once the anterior plate of the anastomosis is completed a cystoscopic retrograde DJ ureteral stent insertion is performed. The procedure ends with the packaging of the posterior plate of the anastomosis with the second running suture.


RESULTS

The operation lasted 180 minutes. The postoperative course was uneventful, the drain was removed on the second day and the bladder catheter on the 4th. The patient was discharged on the 5th day and the DJ ureteral stent was removed on the 21st post-operative day. 


DISCUSSION

The laparoscopic reoperation in patients with previous open surgery interventions is definitely difficult. This kind of surgery has to be carried out after having gained considerable laparoscopy experience. Specifically, the reoperation of laparoscopic pyeloplasty after 2 previous intervention poses the following difficulties: the creation of appropriate space, dissection of the ureter and pelvis from the psoas muscle, appropriate mobilization of the lower pole of the kidney to get a "tension free" anastomosis, liberation of the pelvis and ureter from the tenaciously adherent fibrotic tissue, identification of the stenotic ureteropelvic junction.


CONCLUSIONS

Laparoscopic pyeloplasty after failure of past interventions remains a difficult procedure that should only be performed after major laparoscopic experience. In experienced hands, redo laparoscopic pyeloplasty provides high success rates.

Laparoscopic pyeloplasty: technique and results in 80 consecutive patients

OBJECTIVE

To present our long-term results with the Anderson-Hynes laparoscopic pyeloplasty, performed by a single surgeon.

MATERIAL AND METHODS

Between August 1999 and December 2009, 79 patients (80 procedures) were operated for primary ureteropelvic junction obstruction. We use the Anderson-Hynes technique by a transperitoneal approach. Patients were evaluated with Ultrasound, Excretory urography and dynamic renal scintigraphy (Mag-3). The perioperative characteristics, complications and results were reviewed.

RESULTS

We performed 80 laparoscopic pyeloplasties in 79 patients. Mean operative time was 93.2 minutes (60-180). Crossing vessels were found in 38 of 82 (46.3%) renal units. Kidney abnormalities occurred in 4 patients (1 double ureteropelvic system, one associated retrocaval ureter, 1 horseshoe kidney and one pelvic kidney). Complications occurred in 5 procedures (6.5%): an immediately postoperative bleeding (Clavien 3b), 1 cecal volvulus (Clavien 3b), 1 urosepsis (Clavien 4th) and 1 urinary fistula (Clavien 3a). In this series there was neither mortality nor conversion to open surgery There was recurrence in 3 out of 80 patients (3.7%). They were resolved as follows: 1 percutaneous antegrade endopyelotomy, 1 secondary laparoscopic pyeloplasty and 1 robotic pyeloplasty. There was a 96.3%. of primary overall success rate.

CONCLUSIONS

Our results show that laparoscopic pyeloplasty compares favorably with the result achieved by open surgery. We believe that laparoscopic pyeloplasty is a good surgical alternative for the management of primary ureteropelvic junction obstruction.

The long-term results of laparoscopic retroperitoneal pyeloplasty in adults

Objectives

To report the long-term outcome of laparoscopic retroperitoneal pyeloplasty (LRP) in adults.

Patients and methods

Thirty patients underwent LRP for primary pelvi-ureteric junction obstruction (PUJO). Anderson–Hynes dismembered pyeloplasty was used in 28 patients and a Foley Y–V pyeloplasty in two. A JJ stent was inserted antegradely during the procedure. Patients were reviewed at 1 month after LRP for stent removal, and then at 6 and 12 months routinely, using excretory urography.

Results

The mean patient age was 29.7 years, with a female predominance of 60%. Conversion to open surgery was mandated by dense adhesions secondary to previous pyelonephritis in three patients, and difficulty in suturing in one. The mean (range) operative duration was 228 (190–280) min. There was a crossing vessel in 11 patients and it was not transposed in any. The mean hospital stay after LRP was 4.2 days. The mean (range) follow-up was 60 (29–106) months. Of the 26 patients who had complete laparoscopic procedures, 23 had no evidence of obstruction on long-term postoperative intravenous urography and/or diuretic renography.

Conclusion

LRP combines the high functional success rate of open pyeloplasty in the long term and the minimally invasive morbidity of laparoscopy.

Laparoscopic versus open pyeloplasty: Comparison of two surgical approaches -- a single centre experience of three years

BACKGROUND:

Ureteropelvic junction obstruction (UPJO) causes hydronephrosis and progressive renal impairment may ensue if left uncorrected. Open pyeloplasty remains the standard against which new technique must be compared. We compared laparoscopic (LP) and open pyeloplasty (OP) in a randomized prospective trial.

MATERIALS AND METHODS:

A prospective randomized study was done from January 2004 to January 2007 in which a total of 28 laparoscopic and 34 open pyeloplasty were done. All laparoscopic pyeloplasties were performed transperitoneally. Standard open Anderson Hynes pyeloplasty, spiral flap or VY plasty was done depending on anatomic consideration. Patients were followed with DTPA scan at three months and IVP at six months. Perioperative parameters including operative time, analgesic use, hospital stay, and complication and success rates were compared.

RESULTS:

Mean total operative time with stent placement in LP group was 244.2 min (188-300 min) compared to 122 min (100-140 min) in OP group. Compared to OP group, the post operative diclofenac requirement was significantly less in LP group (mean 107.14 mg) and OP group required mean of (682.35 mg). The duration of analgesic requirement was also significantly less in LP group. The postoperative hospital stay in LP was mean 3.14 Days (2-7 days) significantly less than the open group mean of 8.29 days (7-11 days).

CONCLUSION:

LP has a minimal level of morbidity and short hospital stay compared to open approach. Although, laparoscopic pyeloplasty has the disadvantages of longer operative time and requires significant skill of intracorporeal knotting but it is here to stay and represents an emerging standard of care.

Trends in the treatment of adults with ureteropelvic junction obstruction

BACKGROUND AND PURPOSE

Minimally invasive pyeloplasty is an effective treatment for patients with ureteropelvic junction obstruction that offers quicker convalescence than open pyeloplasty. Technical challenges, however, may have limited its dissemination. We examined population trends and determinants of surgical options for ureteropelvic junction obstruction.

PATIENTS AND METHODS

Using the State Inpatient and Ambulatory Surgery Databases for Florida, we identified adults who underwent ureteropelvic junction obstruction repair between 2001 and 2009. After determining the surgical approach (minimally invasive pyeloplasty, open pyeloplasty, or endopyelotomy), we estimated annual utilization rates and the effects of patient, surgeon, and hospital predictors on surgery type, using multilevel multinomial logistic regression.

RESULTS

Rates of minimally invasive pyeloplasty increased 360% (P for monotonic trend < 0.01), while rates of open pyeloplasty decreased 56% (P<0.01). Rates of endopyelotomy were substantially higher and remained relatively stable (P=0.27). Compared with open pyeloplasty, minimally invasive pyeloplasty was used more commonly among patients with private insurance (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.2-2.3), those treated at teaching hospitals (OR 1.6; CI 1.0-2.6), and those treated by high-volume surgeons (OR 2.9; CI 2.0-4.2). Its use was less frequent among patients with multiple comorbidities (OR 0.53; CI 0.37-0.76). Similar associations were observed when comparing receipt of minimally invasive pyeloplasty with endopyelotomy; however, patients who underwent endopyelotomy were older.

CONCLUSIONS

The use of minimally invasive pyeloplasty has dramatically increased, largely replacing open pyeloplasty, while the use of endopyelotomy, albeit significantly more common than the other approaches, has remained stable. The surgical approach is influenced by several patient, surgeon, and hospital factors.

Robot-assisted pyeloplasty: outcomes for primary and secondary repairs, a single institution experience

INTRODUCTION

Robotic Pyeloplasty (RAP) is a technique for management of ureteropelvic junction obstruction (UPJO).

PURPOSE

To report outcomes of RAP for primary and secondary (after failed primary treatment) UPJO.

MATERIALS AND METHODS

Single institution data of adult RAP performed from 2007 to 2009 was collected retrospectively following approval by our IRB. Database analysis included patient age, race, pre and post-operative imaging studies and perioperative variables including operative time, blood loss, pain and complications.

RESULTS

Fifty-five adult patients underwent RAP (26 left/29 right) for UPJO including 9 secondary procedures from 2007 to 2009. Average follow-up was 16 months (1-36). Mean age was 41 years (18-71) with an average BMI of 27 (17-42); 32 were female. Most patients were diagnosed with preoperative diuretic renal scintigraphy and the obstructed side demonstrated mean function of 41% and t1/2 of 70 minutes. Mean operative time was 194 minutes with average blood loss less than 100 mL. Mean hospital stay was 1.7 days with an average narcotic equivalent dose of 15 mg. RAP for secondary UPJO took longer with more blood loss and had a lower success rate. Failure was defined as the need of another procedure due to persistent pain and/or obstruction after diuretic renal imaging. One patient (2%) with primary UPJO failed and 2 patients (22%) with secondary UPJO failed. One major complication occurred.

CONCLUSION

RAP is a good option for the treatment of patients with UPJO. Reported series have established that endopyelotomy has inferior success rate for the treatment of primary UPJO which compromises the success of subsequent treatment as demonstrated in our higher failure rate with secondary UPJO repair.